Request For Group Coverage/enrollment Form

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Employee Benefit Trust
1205 Windham Parkway
Romeoville, IL 60446
800.807.9460 / 630.378.3005 fax
Request for Group Coverage/Enrollment Form
Due to the Health Insurance Portability and Accountability Act of 1996 (HIPAA), certain provisions contained
within this plan may or may not apply while you are covered. PLEASE READ THE FOLLOWING CAREFULLY.
If you waive (or decline) enrollment for yourself or your dependents because of other health coverage, you may
later enroll within 31 days of a loss of other health coverage. Loss of health coverage includes separation,
divorce, death, termination of employment, reduction in work hours, exhaustion of COBRA continuation or
state continuation, or if employer contributions toward your coverage have terminated.
In addition, any change in your family status may allow you to enroll within 31 days of the event. It includes
marriage, birth, adoption, or placement for adoption of a child. (See Special Enrollment Form)
With the Onset of the Children’s Health Insurance Program Reauthorization Act of 2009 two additional
enrollment opportunities apply for CBEBT Trust members and their enrolled dependents if either of the
following occurs:
Termination of Medicaid or Children’s Health Insurance Program (CHIP) due to loss of eligibility; or
Become eligible for state premium assistance under Medicaid or CHIP.
Trust members and their dependents who are eligible but not enrolled for coverage under the Christian
Brothers Employee Benefit Trust are allowed up to 60 days to request coverage under the group health plan.
Please contact your employer for any clarification regarding your enrollment in the CBEBT.


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